Standard Appeal Process
Who requests an appeal:
- A member or member’s representative (on behalf of the Member with the Member’s written consent) or provider on behalf of a member within 60 calendar days from the date of the Notice of Action letter.
How to request an appeal:
- By phone - call member services at 1-877-860-2837 (TTY/TDD: 711), or
- In writing - mail or fax your written appeal request to:
Blue Cross Community Health Plans Standard Fax: 1-866-643-7069
Attn: Grievance and Appeals Dept. Expedited Fax: 1-800-338-2227
PO Box 660717
Dallas, TX 75266
- Submit all needed clinical information, written comments, documents, or other information about the appeal with the request. Insufficient clinical information may result in a delay in review or an inability to make a fully informed decision.
When will you get a response to a request?
- Appeals will be acknowledged within 3 business days of receipt (all required information must be included)
- The decision and notification, will be provided in writing to the member or member’s authorized representative within 15 business days of receipt of appeal unless a 14-day extension is requested
- If BCCHP plans to take the 14-calendar-day extension, BCBSIL will tell the member, or their representative, no later than two days after the decision is made to extend the time frame. This communication will include:
- The reason for the extension and its benefit for the member
- Further appeal rights including the External Independent Review or State fair hearing process
- How to request
- The Member will be provided access and copies of all documents relevant to the appeal
Expedited Appeal Process
When can you requests an expedited appeal?
- If proposed or continued services pertain to a medical condition that may seriously jeopardize the life or health of a member, or
- If the member has received emergency services and remains hospitalized. If the member is hospitalized, the member may continue to receive services with no financial liability until notified of the decision.
Who requests an expedited appeal:
- A member, a member’s representative, or provider acting on behalf of the member can request oral or written initiation of an expedited appeal.
How to request an expedited appeal:
- Follow the same process for requesting an appeal above.
- BCBSIL will request any necessary information from providers.
When will you get a response to a request for an expedited appeal?
- The decision and notification will be communicated to the member and provider, verbally and in writing as soon as reasonably possible, but no later than 24 hours after receiving all information necessary to evaluate the appeal.
- If there is a decision not to expedite the determination, BCBSIL will provide notification of further appeal rights and the right to file an expedited grievance if the member disagrees
- BCBSIL will provide continued coverage to the member pending the outcome of an external appeal for covered services.